Factors associated with utilization of youth friendly services

In the bivariate logistic regression analyses, being in the age group of 15–19 years [COR?=?0.68, 95 % CI (0.51,0.92)], being a muslim [COR?=?0.71, 95 % CI (0.53–0.96)], being illiterate [COR?=?0.28, 95 % CI (0.12,0.61)] and being 1- 8th grade [COR?=?0.50, 95 % CI (0.33,0.76)], having negative perception about the importance of RH for youth [COR?=?0.34, 95 % CI (0.17–0.68)] and not knowing RH itself [COR?=?0.08, 95 % CI (0.04–0.16)], having negative perception about the importance of contraceptives [COR?=?0.64, 95 % CI (0.43–0.94)] and counseling for youth [COR?=?0.67, 95 % CI (0.49–0.91)], unfavourable attitudes of youth towards the behavior of YFS providers [COR?=?0.50, 95 % CI (0.31–0.80)] and not knowing about their behavoiur itself [COR?=?0.16, 95 % CI (0.11–0.22)] and unfavourable attitudes of youth towards the conduciveness of health service institutions [COR?=?0.45,95 % CI (0.28–0.72)] and not knowing about them [COR?=?0.16, 95 % CI (0.11–0.24)] were negatively associated with utilization of youth friendly services. However, being employed [COR?=?2.72, 95 % CI (1.35,5.51)], having income level of 300–900 ETB [COR?=?2.56,95 % CI (1.53,4.29)], using health care provider as source of information for YFS [COR?=?2.62, 95 % CI (1.09,6.31)], and having knowledge about YFS [COR?=?2.78, 95 % CI (1.99,3.90)] were positively associated with the outcome variable (Table 2).

Table 2

Factors associated with utilization of youth friendly services among youth in Harar town, 2011

ETB Ethiopian birr, COR crude odds ratio, AOR adjusted odds ratio

*p– value???0.05, a private worker and daily laborer

In multivariable logistic regression analysis, using friends [AOR?=?3.65, 95 % CI (1.81,7.32)], health care providers [AOR?=?3.27, 95 % CI (1.18,9.00)] and schools [AOR?=?1.79, 95 % CI (1.00,3.19) as source of information for YFS and having knowledge about YFS [AOR?=?2.77, 95 % CI(1.93,3.96)] were significantly associated with utilization of youth friendly services. In contrast, belonging to other categories by occupation (private worker and daily laborer) [AOR?=?0.12, 95 % CI (0.05, 0.92), not knowing the importance of RH for youth [AOR?=?0.13, 95 % CI (0.04–0.46)], and not knowing whether YFS providers are conducive or not to youth [AOR?=?0.02, 95 % CI (0.08–0.50)] have negatively affected the YFS utilization (Table 2).

The youth who were knowledgeable about YFS were nearly three times more likely to utilize the service compared with their counterparts. The respondents who heard about YFS information from their friends, health care providers, and schools were nearly 4 times, 3.3 times and 2 times more likely to utilize YFS, respectively compared with their counterparts.

Supporting these findings, most of the discussants indicated that the adolescents are reluctant and uncomfortable to discuss RH issues. In most cultures, open discussion of RH issues with parents and significant others is minimal due to the conservative cultural and religious practices. Because of this, the youth do not have adequate information about their RH needs and problems. Most of the discussions between family and the adolescents occur only after certain RH problem has occurred. Most parents are ill-prepared, uncomfortable or awkward in discussing RH issues with their children. This will make adolescents lack knowledge and skills to make rational decision and seek contraceptive or other RH services. Throughout the discussion, culture was repeatedly raised as a factor that prevented the youth from acquiring essential youth SRH services. For example, a 17- year female discussant said “In our culture if you ask about sex related information, others will perceive as if you were already in the process”.

In this study, some of the factors that negatively influenced the utilization of youth friendly reproductive health services were being daily laborer and private worker [AOR?=?0.12, 95 % CI (0.05, 0.92)], having negative perception about counseling [AOR?=?0.50, 95 % CI (0.31–0.80)], about reproductive health services for the youth [AOR?=?0 .13, 95 % CI (0.04–0.46)],and about YFS service providers [AOR?=?0.02, 95 % CI (0.08–0.50)]. One of the major reasons stated in the discussion by the youth for not using the services at the health institutions was feeling discomfort by the conditions of the centers or the attitude of the service providers. Many of these perceptions were resulted from second hand information or general public attitude. For instance, a 21 year- old male discussant who visited the facility for contraceptive described “You know, if you go for family planning, they will ask you about your marital status”. A 22 year- old female discussant also described the experience of her friend’s discomfort about working time as follow: “She went to the youth center to get emergency contraceptive. But the center was closed. Had she been successful, she will be in university today since her pregnancy could have been avoided”. Moreover, a 20 years old male discussant indicated that most of government centers lack separate youth clinics saying “When you go to hospitals for services, you may meet your parents there. I remember my friend who met her mother in a clinic”.

Other youth indicated the importance of establishing recreational/sport facilities and libraries/internet within the youth center. They also indicated that the youth model clinic run by the FGAE has such facility, unlike other government centers. The presence of such facilities will decrease fear of public attitude, beyond being source of information. A 22 year- old female discussant said, “I can go to the center taking my note books with me. There I can get the health service I need. But the public perceive as I went for library. This is impossible in public hospitals “. It was also indicated that such facilities will improve the understanding of the youth about the common RH problems, aware of communication skills, and learn the experience of other youth.

On the other hand, the YFS providers explained that although youth’s RH needs are immense, there are obstacles to access health services. The service providers reported that when the youth reached the centers, passing all obstacles, good decision should be made in support of them. The knowledge and belief of providers play a large role in the kind of information the youth will obtain or the service they will utilize. The sex of the service providers, receiving training or not, judgmental attitude toward adolescent sexual activity and up to date knowledge on such issues were raised as affecting the utilization of the YFS.

Similarly, other respondents of the in-depth interview from public institutions explained that there were no specifically designed SRH services for the youth in their institution. They explained that SRH services are offered for youth without giving them special attention, treating them as adult clients.

Similar to the finding from FGDS with the youth, there are perceptions that giving RH service for adolescents is difficult. For example, according to a male respondent from government hospital, “Family planning should not be given to adolescents; they should be educated only because family planning is good only for married couples. Instead, he suggested discussion about abstinence until marriage”. Moreover, according to a female respondent from another government hospital, “making decision is sometimes difficult, imagine what you would do when you are asked for family planning by a 13 years old female. How I can give this girl a contraceptive?”.

Additionally, the respondents of the in-depth interview were asked whether they have been given training on YFS and approaching the youth politely. The respondents from the family guidance association reported that they have taken such trainings and are confident that they could respond to the needs of the youth. However, the respondents from the government hospitals indicated that they treat the youth like any adult clients. They also reported that they are using their experience to provide YFS but feel not comfortable. One respondent from the government institution said, “…. I have not been offered on the job training on how to provide YFS. Just I am doing what I feel correct from my experience, though I don’t feel comfortable. But I am reading and trying to be a good provider as much as I can….”. Other providers also reported lack of confidence about responding to the needs of youth. A nurse from hospital claimed “…I feel incompetent because sometimes youth ask me so many questions which I can’t fully answer. So I feel even defeated…”

Respondents from both government and non-governmental centers indicated the presence of national guidelines to work on the youth but only those from the non-government centers reported that they are using it.